Credentials Application Process

Step 1

HSHS facilities use an online application process. Complete and submit form below.

Membership/Privileges Application Request Form

Provider Information (All fields are required)

Name:

Location:

HSHS St. John's Hospital in Springfield, ILHSHS St. Mary's Hospital in Decatur, ILHSHS St. Francis Hospital in Litchfield, ILHSHS Good Shepherd Hospital in Shelbyville, IL

Credentials (MD, NP, RN, DO, PA, etc.):

Specialty:

Employer/Group Affiliation:

Anticipated Start Date:

Phone number:

()-First three digitsSecond three digitsLast four digits

Cell phone number:

()-First three digitsSecond three digitsLast four digits

Email:

Re-enter Email:

Comments:

Use this space to note any issues we need to be aware of regarding this application.

Security code:

Enter security code:

Step 2

Once Medical Staff Services receives your request form you will receive an email with a link to the online application website, your username and password and a list of the applicable forms required.

Step 3

Complete and submit the online application and upload any supporting documentation (licenses, malpractice coverage, etc.), including the Illinois State Credentialing Application and privileges forms. You may also scan and email documentation to Medical Staff Services or fax to (217) 525-5673 (St. John’s), (217) 464-3144 (St. Mary’s) or (217) 324-8670 (St. Francis and Good Shepherd).

Step 4

There is a non-refundable application fee for each facility. Please make out your check to the facility to which you are applying for the appropriate amount and mail it to the address below.